Striving for seamlessly integrated care Eric Monteiro Norwegian Univ. of Science & Technology and Univ. of Oslo www.idi.ntnu.no/~ericm
Local solutions • Artefacts in use • workplace studies • ethnographies • contingencies, glitches, situated action • small commuties of practice • Artefacts in context • prototyping • users, participation Pelle Ehn & Scandinavia
Beyond the local: vertical & horizontal How similar ? - granularity Standardisation ! Dependencies with Others ? - scope Integration !
Standardisation: Example • Portal Rikshospital • 556 systems, 160 clinical • Role-based, in principle • ex.: order entry • ”Too much details” (Rikshospitalet, GK Bruun)
Standardisation: Example “… but for us it is not helpful …. Just consider that you have to scroll the listbox [the list of analyses codes]. This also means that there are too many available options for the physician ordering a test…. Mixing everything together in a big chunk on the working lists has caused a problem for several departments because they want Microbiology results separated from the mass produced blood results ”
Standardisation: Analytical perspective • Standards as co-constructed practice • top-down enforced but also … • improvised locally • Relocate – not remove - work-arounds • J Grudin, revisited • benefits for whom? additonal work ? • Inherent, immanent ?? “The order and its disorder…. need and embody each other… The orders … produce the very disorder they attempt to eradicate” (Timmermans and Berg, 2000)
Integration: Example Pharmacy GP prescription identifier Record sys. inventory sys. list of products Vendor Catalogue NMD Fabritius
Integration: Example • data standards • reporting • indicators DHIS GIS ART/HIV Morbidity & Mortality Scheduler/FMHIS (www.hispindia.org) Adm/budgetting
Analytic (I): ”Change, to remain the same” • change contents • different parts • different versions • different configurations • change context • community based • drilling equipment • Is Z Bush Pump an artefact ?? • Fluid Zimbabwe bush pump
Analytical perspective (II) • Integration = add dependencies • integration ALSO multiplication & propagation of unintended consequences • removing slack (delay, quality ensurance, double check) • Complex + tightly coupled (C Perrow) • difficult to recognise outcomes (risks) • effects interact, travel • Integration • part of the solution or … • part of the problem ?
From Artefacts to Infrastructures Standardisation • Architecture vs Urban planning • houses vs neigherhood • blend in = ... ? • Heterogenous integration • oppose idealisations/abstractions • curb totalizing inclination/ambitions • ”Complexify concepts in response to complex phenomena” (Tsoukas) Integration